Provider Demographics
NPI:1447831722
Name:GOMEZ PANTOJA, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:GOMEZ PANTOJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 SW 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:786 S HOMESTEAD BLVD
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-7352
Practice Address - Country:US
Practice Address - Phone:305-242-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-18
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN283981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice